| Values |
| Female |
| Male |
| prefer not to disclose |
| X |
| Field Name | Data Type | Value |
| Program | Dropdown | Hearing and Speech |
| Professions | Dropdown | Speech Language Pathologist |
| Speech Language Pathologist Interim Permit | Checkbox | True |
| Field Name | Data Type |
| Street | Text |
| City | Text |
| Country | Dropdown |
| State | Dropdown |
| Zip Code | Text |
| County | Text |
| Field Name | Data Type |
| Phone Number | Phone |
| Cell Number | Phone |
| Email Address |
| Field Name |
| Middle Name |
| First Name |
| Last Name |
| Date of Birth (mm/dd/yyyy) |
| Social Security Number |
| Gender |
| Field Name | Data Type | Value |
| Country | Dropdown | United States |
| Field Name | Data Type |
| State | Dropdown |
| Field Name |
| County |
| Field Name | Data Type | Value |
| Zip Code | Text | 12346789 |
| Error Message |
| Invalid ZipCode Format |
| Field Name | Data Type | Value |
| Country | Dropdown | Canada |
| Field Name | Data Type |
| State | Dropdown |
| Field Name | Data Type | Value |
| Zip Code Canada | Text | 12345 |
| Error Message |
| Invalid ZipCode Format |
| Field Name | Data Type | Value |
| Country | Dropdown | Afghanistan |
| Field Name | Data Type |
| State | Text |
| Field Name |
| County |
| Field Name |
| Alternate Names: |
| Field Name | Data Type | Value |
| Alternate Names: | Text | Auto |
| Field Name | Data Type |
| Street | Text |
| City | Text |
| Country | Dropdown |
| State | Dropdown |
| Zip Code | Text |
| County | Text |
| Field Name | Data Type |
| Street | Text |
| City | Text |
| Country | Dropdown |
| State | Dropdown |
| Zip Code | Text |
| County | Text |
| Field Name | Data Type | Value |
| Country | Dropdown | United States |
| Field Name | Data Type |
| State | Dropdown |
| Field Name | Data Type | Value |
| Zip Code | Text | 123456789 |
| Error Message |
| Invalid ZipCode Format |
| Field Name | Data Type | Value |
| Zip Code | Text | 12345 |
| Field Name | Data Type | Value |
| Country | Dropdown | Canada |
| Field Name | Data Type |
| State | Dropdown |
| Field Name | Data Type | Value |
| Zip Code Canada | Text | 12345 |
| Error Message |
| Invalid ZipCode Format |
| Field Name | Data Type | Value |
| Zip Code Canada | Text | 123456789 |
| Field Name | Data Type | Value |
| Country | Dropdown | Afghanistan |
| Field Name | Data Type |
| State | Text |
| Error Message |
| Error: 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? is required. |
| Error: 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? is required. |
| Error: 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism? is required. |
| Error: 4. Are you currently engaged in the illegal use of controlled substances? is required. |
| Error: 5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? is required. |
| Error: 6a. Possessed, used, prescribed for use, or distributed Controlled Substances or Legend drugs in any way other than for legitimate or therapeutic purposes? is required. |
| Error: 6b. Diverted controlled substances or legend drugs? is required. |
| Error: 6c. Violated any drug law? is required. |
| Error: 6d. Prescribed controlled substances for yourself? is required. |
| Error: 7. Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a healthcare profession? is required. |
| Error: 8. Have you ever had any license, certificate, registration or other privilege to practice a healthcare profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? is required. |
| Error: 9. Have you ever surrendered a credential like those listed in number 8, in connection with or to avoid action by a state, federal, or foreign authority? is required. |
| Error: 10. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of the healthcare profession? is required. |
| Error: 11. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)? is required. |
| Field Name | Data Type | Value |
| 1a. Please explain medical condition. | Textarea | Test Medical Condition |
| 1b. Please explain how your treatment has reduced or eliminated the limitations caused by your medical condition. | Textarea | Test Limitations |
| 1c. Please explain how your field of practice, the setting or manner of practice has reduced or eliminated the limitations caused by your medical condition. | Textarea | Test limitations caused by your medical condition |
| Field Name | Data Type | Value |
| 2a. Chemical Substance Explanation | Textarea | Test Chemical Substance |
| Field Name | Data Type | Value |
| 3a. Diagnosis Explanation | Textarea | Test Diagnosis Explanation |
| Field Name | Data Type | Value |
| 4a. Controlled Substances Explanation | Textarea | Test illegal issue |
| Bold Text |
| Note: If you answer 'yes' to any of the remaining questions, provide an explanation and certified copies of all judgements, decisions, orders agreements and surrenders. The department does criminal checks on all applicants. |
| Field Name | Data Type | Value |
| 5a. Conviction Explanation | Textarea | Test Conviction Explanation |
| Bold Text |
| Note: Since you answered 'yes' to question 5, you must send certified copies of all court documents related to your criminal history with your application. If you do not provide the documents, your application is incomplete and will not be considered. If you have been granted certificate(s) of restoration of opportunity, please provide a certified copy of each certificate. |
| To protect the public, the department considers criminal history. A criminal history may not automatically bar you from obtaining a credential. However, failure to report criminal history may result in extra cost to you and the application may be delayed or denied. You will have the ability to upload documents on the supporting documentation step in this application. |
| Field Name | Data Type | Value |
| 6a. Controlled Substance Legal Explanation | Textarea | Test Controlled Substances Explanation |
| Field Name | Data Type | Value |
| 6b. Criminal Proceedings Explanation | Textarea | Test Criminal Proceedings |
| Field Name | Data Type | Value |
| 6c. Drug Law Violations Explanation | Textarea | Test Drug Law |
| Field Name | Data Type | Value |
| 6d. Self Prescribed Controlled Substance Explanation | Textarea | Test Self Prescribed |
| Field Name | Data Type | Value |
| 7a. Violation of State or Federal Law Explanation | Textarea | Test Violation of state |
| Field Name | Data Type | Value |
| 8a. License, Certificate, Registration Issue Explanation | Textarea | Test License Certificate |
| Field Name | Data Type | Value |
| 9a. Surrender Explanation | Textarea | Test surreender explanation |
| Field Name | Data Type | Value |
| 10a. Civil Judgement Explanation | Textarea | Test Civil Judgement |
| Field Name | Data Type | Value |
| 11a. Vulnerable Persons Disqualification Explanation | Textarea | Test Vulnerable persons |
| Field Name | Data Type | Value |
| 1. Enter your National Provider Identifier (NPI) Number if available. | Text | 123456 |
| Field Name | Data Type | Value |
| 1. Enter your National Provider Identifier (NPI) Number if available. | Text | 1234567890 |
| Error Message |
| NPI is 10 digits. |
| Link |
| Add |
| Error Message |
| Please add at least one other license, certificate or registration |
| Link |
| Add |
| Error Message |
| Country is required. |
| Credential Type is required. |
| Profession is required. |
| Credential Type is required. |
| Credential Number is required. |
| Issue Date is required. |
| Expiration Date is required. |
| Is this credential currently in an active status? is required. |
| How did you receive this credential? is required. |
| Field Name | Data Type | Value |
| How did you receive this credential? | Dropdown | Grandparented |
| Country | Dropdown | United States |
| State or Province | Dropdown | Alabama |
| Profession | Text | Test Doctor |
| Credential Type | Dropdown | Temporary |
| Credential Number | Text | 12345678 |
| Issue Date | Date | Today - 100 |
| Expiration Date | Date | Today - 0 |
| Field Name | Data Type | Value |
| Credential Number | Text | 23456789 |
| Field Name | Value |
| Credential Number | 23456789 |
| Error Message |
| Error: Business Name is required. |
| Error: Address Line 1 is required. |
| Error: City is required. |
| Error: Zip Code is required. |
| Error: State or Province is required. |
| Field Name | Data Type | Value |
| Business Name | Text | Test Business Name |
| Address Line 1 | Text | Test Address Line 1 |
| Address Line 2 | Text | Test Address Line 2 |
| City | Text | Test test |
| Zip Code | Text | 12345 |
| State or Province | Dropdown without scroll | Alabama |
| Text |
| Based on your responses we recommend you contact us regarding your application. You may contact us at |
| Error Message |
| Error: Name of the Registered Agent is required. |
| Error: Address Line 1 is required. |
| Error: City is required. |
| Error: State or Province is required. |
| Error: Zip Code is required. |
| Field Name | Data Type | Value |
| Name of the registered Agent | Text | Test Agent |
| Address Line 1 | Text | Test Address Line 1 |
| Address Line 2 | Text | Test Address Line 2 |
| City | Text | Test test |
| Zip Code | Text | 12345 |
| State or Province | Dropdown without scroll | Alabama |
| Error Message |
| Please add at least one. |
| Field Name | Data Type | Value |
| Country | Dropdown | United States |
| State or Province | Dropdown | Alabama |
| City | Text | test city |
| School or Training Program Name | Text | test School |
| School Type | Dropdown | College/University |
| Date From | Date | Today - 100 |
| Date To | Date | Today - 0 |
| Type of Degree | Text | Test Type of Degree |
| Attendance Status | Dropdown | Graduated |
| Field Name |
| Graduation Date |
| Field Name | Data Type | Value |
| Attendance Status | Dropdown | Attending |
| Field Name |
| Graduation Date |
| Link |
| Edit |
| Delete |
| Error Message |
| Business Name is required. |
| Type of Experience/Specialty is required. |
| City is required. |
| Country is required. |
| Start Date is required. |
| End Date is required. |
| Field Name | Data Type | Value |
| Business Name | Text | Test Business Name |
| Type of Experience/Specialty | Text | test experiencee type |
| City | Text | test city |
| Country | Dropdown | United States |
| State or Province | Dropdown | Alabama |
| Start Date | Date | Today - 50 |
| End Date | Date | Today - 0 |
| Field Name |
| *End Date |
| Text |
| Are you the spouse or registered domestic partner of military personnel? |
| Other License, Certifications or Registrations |
| Text |
| Official Transcripts |
| Jurisprudence Examination |
| Acknowledgment of Responsibility for Interim Form |
| Additional Information |
| Error Message |
| Please check the checkbox. |
| Field Name | Data Type | Value |
| I agree. | Checkbox | true |
| Field Name | Values |
| Dated: | Today - 0 |
| Initials: | AT |
| Field Name |
| 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? |
| 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? |
| 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism? |
| 4. Are you currently engaged in the illegal use of controlled substances? |
| 5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? |
| 6a. Possessed, used, prescribed for use, or distributed Controlled Substances or Legend drugs in any way other than for legitimate or therapeutic purposes? |
| 6b. Diverted controlled substances or legend drugs? |
| 6c. Violated any drug law? |
| 6d. Prescribed controlled substances for yourself? |
| 7. Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a healthcare profession? |
| 8. Have you ever had any license, certificate, registration or other privilege to practice a healthcare profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? |
| 9. Have you ever surrendered a credential like those listed in number 8, in connection with or to avoid action by a state, federal, or foreign authority? |
| 10. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of the healthcare profession? |
| 11. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)? |
| 1. Enter your National Provider Identifier (NPI) Number if available. |
| Are you the spouse or registered domestic partner of military personnel? |
| Country |
| State or Province |
| Profession |
| Credential Type |
| Credential Number |
| Issue Date |
| Expiration Date |
| Is this credential currently in an active status? |
| How did you receive this credential? |
| Country |
| State or Province |
| City |
| Field Name |
| First Name |
| Last Name |
| Date of Birth (mm/dd/yyyy) |
| Social Security Number |
| Gender |
| Street |
| City |
| Country |
| Zip Code |
| County |
| Phone Number |
| Cell Number |
| Email Address |
| Expiration Date |
| Issue Date |
| Text |
| There is a $2.50 convenience fee required to use the online service when paying by credit card/debit card. The amount will be charged in addition to your fee(s). There is no additional convenience fee for ACH payments. |
| Fees submitted with applications for initial credentialing, examinations, renewal and other fees associated with the licensing and regulation of the profession are nonrefundable. |
| Link |
| WAC 246-12-340. |
| Field Name |
| First Name |
| Last Name |
| Date of Birth (mm/dd/yyyy) |
| Social Security Number |
| Gender |
| Street |
| City |
| Country |
| Zip Code |
| County |
| Phone Number |
| Cell Number |
| Email Address |
| 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? |
| 1a. Please explain medical condition. |
| 1b. Please explain how your treatment has reduced or eliminated the limitations caused by your medical condition. |
| 1c. Please explain how your field of practice, the setting or manner of practice has reduced or eliminated the limitations caused by your medical condition. |
| 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? |
| 2a. Chemical Substance Explanation |
| 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism? |
| 3a. Diagnosis Explanation |
| 4. Are you currently engaged in the illegal use of controlled substances? |
| 4a. Controlled Substances Explanation |
| 5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? |
| 5a. Conviction Explanation |
| 6a. Possessed, used, prescribed for use, or distributed Controlled Substances or Legend drugs in any way other than for legitimate or therapeutic purposes? |
| 6a. Controlled Substance Legal Explanation |
| 6b. Diverted controlled substances or legend drugs? |
| 6b. Criminal Proceedings Explanation |
| 6c. Violated any drug law? |
| 6d. Prescribed controlled substances for yourself? |
| 6d. Self Prescribed Controlled Substance Explanation |
| 7. Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a healthcare profession? |
| 7a. Violation of State or Federal Law Explanation |
| 8. Have you ever had any license, certificate, registration or other privilege to practice a healthcare profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? |
| 8a. License, Certificate, Registration Issue Explanation |
| 9. Have you ever surrendered a credential like those listed in number 8, in connection with or to avoid action by a state, federal, or foreign authority? |
| 9a. Surrender Explanation |
| 10. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of the healthcare profession? |
| 10a. Civil Judgement Explanation |
| 11. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)? |
| 11a. Vulnerable Persons Disqualification Explanation |
| 1. Enter your National Provider Identifier (NPI) Number if available. |
| Are you the spouse or registered domestic partner of military personnel? |
| State or Province |
| Profession |
| Credential Type |
| Credential Number |
| Issue Date |
| Expiration Date |
| Is this credential currently in an active status? |
| How did you receive this credential? |
| Timestamp | TestName | Status |
|---|---|---|
| Oct 26, 2022 03:02:01 PM | Validating the Intake Flow of Speech Language Pathologist License and Speech Language Pathology Assistant Certification.6.Validate the flow of Speech Language Pathologist License and Speech Language Pathology Assistant Certification Intake flow - Speech Language Pathologist Interim Permit | pass |
| Name | Value |
|---|---|
| User Name | prince.gupta_mtxb2b |
| Time Zone | Asia/Calcutta |
| Machine | Windows 10 - 64 Bit |
| Selenium | 3.7.0 |
| Maven | 3.6.3 |
| Java Version | 1.8.0_151 |
| Name | Passed | Failed | Others | Passed % |
|---|---|---|---|---|
| @SpeechLanguagePathologyCertification1 | 1 | 0 | 0 | 100% |